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Family Name:

Case No.:

Case Date:

Worker Name:	Family and Child Connect IFS (FaCC referral) IFS (direct referral) Agency name and catchment:
Primary Parent:	Assessment Commencement Date:
Secondary Parent:	Is any child: Aboriginal Torres Strait Islander Both

NEGLECT SCORE N1. Current concern a. Does not include neglect b. Includes neglect     N2. Prior Child Safety notifications for abuse/neglect a. None b. One c. Two or more.     N3. Prior ongoing Child Safety intervention a. No prior ongoing intervention b. Prior ongoing intervention with the household     N4. Prior out-of-home placement a. No b. Yes     N5. Number of children living in the referred household a. One, two or three children b. Four or more children     N6. Age of youngest child in the home a. Two or older b. Under 2     N7. Characteristics of children in the household a. None b. One or more apply.. Developmental or physical disability Medically fragile/failure to thrive Positive toxicology screen at birth     N8. Current housing a. Family has safe, stable shelter b. One or more apply.. Physically unsafe Family homeless     N9. Physical care of child by primary parent a. Consistent with child needs b. Inconsistent with child needs     N10. Primary parent history as a child a. No abuse or neglect b. Experienced abuse or neglect     N11. Primary parent mental health a. No past or current problem b. Past or current mental health problem During the last 12 months At any other time prior to that     N12. Primary parent drug or alcohol use a. No past or current problem b. Past or current drug or alcohol problem During the last 12 months At any other time prior to that     N13. Primary parent criminal history a. No criminal history as adult or juvenile b. Criminal history as adult or juvenile     NEGLECT SCORE 0

ABUSE SCORE A1. Current concern a. Does not include physical injury or substantial risk of physical injury b. Includes physical injury or substantial risk of physical injury     A2. Prior Child Safety notifications for abuse/neglect a. None b. One c. Two or more.     A3. Prior ongoing Child Safety intervention a. No prior ongoing intervention b. Prior ongoing intervention with the household     A4. Was a child injured resulting from past abuse/neglect? a. No b. Yes     A5. Number of children living in the referred household a. One, two or three children b. Four or more children     A6. Primary parent a. Does not justify abuse/neglect b. Justifies abuse/neglect     A7. Household relationships a. No domestic or family violence in past year b. Domestic or family violence in past year     A8. Characteristics of primary parent a. Provides sufficient emotional/psychological support; uses effective, safe discipline; sets reasonable rules and expectations b. One or more apply Provides insufficient emotional/psychological support Employs excessive/inappropriate discipline Domineering parent     A9. Primary parent history as a child a. No abuse or neglect b. Experienced abuse or neglect     A10. Primary parent mental health a. No past or current problem b. Past or current mental health problem During the last 12 months At any other time prior to that     A11. Parent alcohol and/or drug use a. Neither parent has or had alcohol or drug problem b. One or both parents have/had alcohol and/or drug problem Primary parent - During the last 12 months Secondary parent - During the last 12 months Primary parent - Any other time prior to that Secondary parent - Any other time prior to that     A12. Primary parent criminal history a. No criminal history as adult or juvenile b. Criminal history as adult or juvenile     ABUSE SCORE 0

OVERRIDE SECTION:

Policy override to high: Select yes if any condition is applicable; final risk level is high.
Yes No	1. Non-accidental injury to a child under age 3 years (current).
Yes No	2. Severe non-accidental injury by a parent (previous or current).
Yes No	3. Parent caused death of a child due to abuse or neglect (previous or current).

Discretionary override: